HomeMy Public PortalAbout9030 PENTLAND ST_Plumbing__ ZER S COMPENSATION DECLARATION WOO DPW 9/69 -
A APPLICATION FOR PLUMBING PERMIT
IV,rffirm that I have a certificate of consent to self insure .
or a certdicete of Vrprker`s Compensation Insurance or a certified , I-
copyjthereoi(See 38800 Lab C)
POlr�QZ'Y�"G7i Company �Y✓�T� ��� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
❑ Certified copy Is hereby fumished }
❑
DING
FOR APPLICANT TO FILL IN(PRINT OR TWE)Certified copy M filed with the county building inspeco
tin ADDRESS
department /}�, / /c�i✓J --f.. NUMBER FIXTURE OR ITEM Qy FEE
Date 9—L' — APPllcant 17% 64G V&4f?T/ LOCALITY r�
WATER CLOSET J NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS r BATH TUB CROSS ST
COMPENSATION INSURANCE ASSESSOR p,
(This section need not be completed If the work Involved by the SHOWER MAP BOOK PJ 8 PAGE z(� PARCEL
penult is for one hundred dollars($100)or less) LAVATORY OWNER ( t C
I certify that in the performance of the work for which this permit
ie issued I shell not employ any person in any manner so as toSINK ADDMAILRESS
become sub/act to the Workers Compensation Laws /+
DISWASHER CITY / L+/ TEL NO
Date - Applicant CLOTHES WASHER r C'
NOTICE TO APPLICANT If after making this Certific of CONTRACTOR',UL/n1.A L2�Z Ef2�
Exemption you should become subfect to the Workers Compensation SWIMMING POOL RECEPTOR VOW
,
provisions of the Labor Code you must forthwith comply with such ADDRESS OW
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM '/
LICENSED CONTRACTORS DECLARATION CITY/ (ri/7 TEL NO 1'
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER Iq L
(commencing with Section 7000) of Division 3 of the Business and STATE �s/0 CLASS LIC O
Professions Code and my license is in full force and effect GAS SYSTEM OUTLETS LICENSE NO /.) 0
OUTLETS OVER DISTRICT'uW PR SSED BY Q
5 PER SYSTEM 5,A (f Q
License Number 4s�o yo Lic Class V CCCJJI F_
,tet,` FINAL 1 W
Contractor _57_4 v 611-14F BAM"� /�(/_y DATE VALIDATION a
❑ Z
I am exempt under Sec t FINAL
B 8P C for this reason 'd
Date Plan check fee ,
Signature PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE
C
SINGLE FAMILY Plan check applicant 4
HOME OWNER BUILDER DECLARATION Name (f�,L (f C • RCL�.i
I hereby affirm that I am exempt from the Contractors License Lew _
for the following reason (Section 7031 5 Business and Professions Address Z7 4l rj /i�� d_IJP 68.40
Code)
❑ C't)4 Tal No 83C) i 1 ITEfl:
I as owner of the property will do the work and the structure
is not Intended or offered for sale (Section 7044 Business ++ l I CITAL 68B . 40
and Professions Code) s , CHECK h
' 1°,.411
CONSTRUCTION LENDING AGENCY
I hereby affirm that mere is a construction lending agency for the ` r '
CHlahh�E L10
performance of the work for which this permit is Issued (Sec 3097 1, -
Civ C) . TIj
Lender s Name (y
/ V'J W.)—oyj 1 9/18/12
�4�d1 1 Afl S:52
Lenders Address
I certify that I have reed this application and stele that the above ,
Information is correct I agree to comply with all County ordinances '
e d tete laws regulat Plumbing and hereby authorize
pre matives of Ihi ou ty to enter upon the above mentioned `
op y lar Inspect n pur sesSEE REVERSE FOR EXPLANATORY LANGUAGE
�_/<---'Z_,
Signature of P,15wttee Date